Nursing Elites

1. A nurse is reviewing the plan of care for a client who is in the manic phase of bipolar disorder. Which of the following interventions should the nurse expect to include?

• A. Encourage group activities to promote socialization.
• B. Encourage the client to take frequent naps throughout the day.
• C. Provide the client with frequent high-calorie snacks.
• D. Promote physical activity during mealtimes to stimulate appetite.

Correct answer: C

Rationale: Providing high-calorie snacks is essential when caring for a client in the manic phase of bipolar disorder because they often have increased energy expenditure and may not eat adequately due to their heightened activity levels. Encouraging group activities (Choice A) may overwhelm the client further during this phase. Encouraging frequent naps (Choice B) contradicts the need to manage increased energy levels. Promoting physical activity during mealtimes (Choice D) may not be appropriate as it can distract the client from eating, which is crucial in meeting their nutritional needs.

2. A nurse is caring for a client who is 4 hours postoperative following an open cholecystectomy. Which of the following actions should the nurse take?

• A. Monitor the client's urinary output.
• B. Assist the client to splint the incision with a pillow when coughing.
• C. Provide the client with a clear liquid diet.
• D. Encourage the client to ambulate in the hallway.

Correct answer: B

Rationale: Assisting the client to splint the incision with a pillow while coughing is the correct action in this scenario. This intervention helps reduce pain and prevent wound dehiscence, which is the partial or complete separation of the layers of a surgical wound. Monitoring urinary output is important but not the priority at this immediate postoperative stage. Providing a clear liquid diet may be indicated later but is not the most immediate concern. Encouraging ambulation is beneficial for preventing complications like deep vein thrombosis, but splinting the incision is more crucial at this early postoperative period.

3. A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the following interventions should the nurse implement?

• A. Provide a low-sodium diet.
• B. Administer lorazepam as prescribed.
• C. Keep the client in a supine position.
• D. Place the client in restraints as prescribed.

Correct answer: B

Rationale: Administering lorazepam is the appropriate intervention for a client experiencing acute alcohol withdrawal. Lorazepam helps reduce agitation and prevent complications during this withdrawal phase. Choice A, providing a low-sodium diet, is not directly related to managing alcohol withdrawal symptoms. Choice C, keeping the client in a supine position, is not necessary and may not address the client's withdrawal symptoms. Choice D, placing the client in restraints, should only be considered if the client is at risk of harming themselves or others, but it is not the primary intervention for managing alcohol withdrawal.

4. A charge nurse is teaching a group of nurses about delegation. Which task should the nurse delegate to assistive personnel (AP)?

• A. Teaching a new mother how to breastfeed.
• B. Assisting a client with ambulation post-surgery.
• C. Helping with medication administration.
• D. Delegating IV medication administration.

Correct answer: B

Rationale: The correct answer is B. Assisting a client with ambulation post-surgery is a task that can be appropriately delegated to assistive personnel (AP) as it falls within their scope of duties. Teaching a new mother how to breastfeed and helping with medication administration involve assessments and critical thinking that are typically within the scope of licensed nursing staff, not AP. Delegating IV medication administration involves a higher level of skill and knowledge that should be performed by licensed nursing staff.

5. A nurse is planning care for a client who practices Orthodox Judaism and is observing the Passover holiday. Which of the following actions should the nurse include in the plan of care?

• A. Provide chicken with cream sauce.
• B. Avoid serving fish with fins and scales.
• C. Provide unleavened bread.
• D. Avoid serving foods containing lamb.

Correct answer: C

Rationale: During the Passover holiday, individuals practicing Orthodox Judaism follow dietary restrictions that include avoiding leavened bread. Providing unleavened bread aligns with these restrictions and ensures the client's observance of the holiday. Choices A, B, and D are incorrect because serving chicken with cream sauce, avoiding fish with fins and scales, and avoiding foods containing lamb are not specific dietary requirements related to observing Passover in Orthodox Judaism.

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